Tennessee Nurse RaDonda Vaught - Legal Perspectives of Fatal Medication Error

[Lorie Brown RN, MN, JD]

Unless you've been living under a rock. You know all about RaDonda Vaught, the Tennessee Nurse who made a terrible and tragic fatal medication error. I won't go over all the details of the case here since there have already been multiple articles in the news and on allnurses.com. I will share more in the video below. As a nurse attorney, I want to give some legal perspectives about this case.

The Basics

• Charlene Murphy (let's not forget about her) - a patient undergoing a CAT scan
• RaDonda Vaught - nurse with 2 years of experience working as a help-a-nurse
• The Doctor (whose name has not been spread all over the news) ordered Versed
• RaDonda overrode the Pyxis and erroneously retrieved Vecuronium instead of Versed
• RaDonda failed to perform the 5 Rights of Medication Administration
• The fatal dose of Vecuronium administered to Charlene Murphy
• RaDonda still has an active license
• Vanderbilt Medical Center did not tell the family about the medication error until a year later.

Questions

• Did Vanderbilt Medical Center have policies and procedures for the administration of Versed including monitoring?
• Why didn't the family learn the truth of the matter until a year after CMS investigated?
• Should RaDonda be found guilty of Reckless Homicide and receive a prison sentence?
• In the State of Tennessee, what is Reckless Homicide?
• Why did RaDonda plea not guilty?
• What precedent might the outcome of this case set?

The real issue in Radonda's situation is "did this amount to reckless homicide?” I do not agree that it did. Flat out negligence, no question about it. Medical malpractice, no question about it. I have no idea what a jury will decide should RaDonda's case go to trial. What would your vote be if you were sitting on the jury? Guilty or Not Guilty?

If you find yourself of the opinion that "yes", RaDonda should be criminally prosecuted, keep in mind that this could be you!

Please watch the video below and find out the answers to some of the questions posted above. Then, share your comments below.

[Here.I.Stand, BSN, RN]

3 hours ago, Wuzzie said:

Yet, outside of you the vast majority of people who think RV is innocent have verbalized that there just weren’t enough warnings so it couldn’t possibly be her fault. So which is it?

Right? Up to and including “this is a NMB and patient won’t be able to breathe if you give it. Not breathing means they will die” or some other foolish proposed warning.... right up there with Warning: don’t operate this blow dryer while in the shower.

I get that imperfect systems can lead to errors. But sometimes it really is the nurse’s fault! I honestly can’t see anything that even partially excuses this, other than gross incompetence.

Not even Vec’s presence in the Omnicell. Yes there ARE instances when an ICU nurse might need it, other than for an RSI.

It’s not up to technology to safely administer meds — it’s up to US. How many times have we said we are the last line of defense before a treatment reaches the pt?? RV did nothing and exhibited zero nursing judgment. (Slam an IV push med and then leave to do a swallow study?? Are you ******* kidding?? The mere fact that a nurse and not a SLP checking that pt’s swallow means that that pt isn’t at extreme risk of aspiration right then. A prudent nurse would have told whoever asked her to do the swallow study “No” or “I will be by after I see to this pt.”)

Of course, if she had checked the label or the cap or the warnings... CHARLENE MURPHEY... remember the human being who RV killed? would be alive.

[KarenMS]

On 3/2/2019 at 6:46 AM, HomeBound said:

Um.....its hyperbole, not an actual event. Please. With the over the top emotion.

I think you may want to save your outrage for something really scary, such as drunk drivers, high drivers or road rage.

Geezus.

You must be joking. It’s entirely appropriate to be appalled at someone who claims they text and drive and that it’s really no big deal.

If if you don’t actually text and drive, and it was really “hyperbole” then you need to learn how to convey that in a better way, because “I text and drive” isn’t clearly a hyperbolic statement. It looks like a statement of fact.

[Scrunchkin78, ADN, BSN, MSN]

On 4/12/2019 at 5:51 PM, RegisterednurseRN02 said:

I think she majorly ***** up! That is my opinion! But, it was not intentional! I think if we start hating on people in healthcare who do make mistakes that even some of us deem INAPPROPRIATE mistakes, people are going to be scared to become healthcare employees! It won't be worth it eventually! Yaya, check this check that, she made an effed up mistake. There is NO doubt..it was a horrible mistake! I personally think the simple solution is doing the 5 patient rights but that concept she clearly knew..I am 100% sure if she knew she was going to make this fatal error that day, she would of CALLED IN! There is a fine line between accepting that this person made a horrific mistake and deamonizing (sp) this person as well. It could have been ANY of us!!!!

Read this story: this nurse was an OB nurse for years maybe 20...and mixed up a medication while caring for a pregnant teen! This woman was given her license back but would not take it back! She worked overtime and slept in a hospital bed for 4 hours because they did not have staff for the next shift over the 4th of July. This is a horrible error, but being human, it could have been ANY of us..HER OWN EYES saw the wrong med on the medication bag...she DID HER CHECK and her own exhaustion failed her! It is heartbreaking and scares me to death to be an RN!!!

https://madison.com/news/state-nurse-error-caused-death-st-mary-s-hospital-could/article_a757c9c3-075e-5ff7-accf-2a6686e00ead.html

I am so sick of people saying this could happen to anyone...NO...unless you are an incredibly sloppy useless nurse, this will NOT happen to you. What you are really saying is you are afraid this can happen to you and you don’t want to go to jail. Tough ****...be a better nurse and stick to what you are taught. It is complete BS to blow off the lethal malpractice and pure negligence that killed a human and say “whoops! It can happen to everyone.” No, she didn’t mean to kill the lady...but neither do drunk drivers that run over pedestrians, or truck drivers that fall asleep behind the wheel. She took an oath to do no harm and then she broke every safety rule in the book killing a person - she’s guilty and deserves to go to jail. No one should be exempt from punishment when it comes to the negligent killing of a human. Just because we are nurses does not give us the right to **** up and kill someone.

[Luchador, CNA, EMT-B]

On 4/12/2019 at 10:33 PM, Scrunchkin78 said:

I am so sick of people saying this could happen to anyone...NO...unless you are an incredibly sloppy useless nurse, this will NOT happen to you. What you are really saying is you are afraid this can happen to you and you don’t want to go to jail. Tough ****...be a better nurse and stick to what you are taught. It is complete BS to blow off the lethal malpractice and pure negligence that killed a human and say “whoops! It can happen to everyone.” No, she didn’t mean to kill the lady...but neither do drunk drivers that run over pedestrians, or truck drivers that fall asleep behind the wheel. She took an oath to do no harm and then she broke every safety rule in the book killing a person - she’s guilty and deserves to go to jail. No one should be exempt from punishment when it comes to the negligent killing of a human. Just because we are nurses does not give us the right to **** up and kill someone.

+1000

If the Tennessee bon did their job charges would not have been pressed.

[Workitinurfava, BSN, RN]

Your spiritual body will leave the building long before your physical body. What a shame.

[Hoosier_RN, MSN]

As far as checking the vial, even if she had selected the correct med in the Pyxis computer lineup, she still could have gotten the wrong med. Years ago, when the last hospital I worked at first got the Pyxis, a pharm tech accidentally loaded heparin into an insulin bin-this was before warnings were blaring on heparin vials. Luckily, it was caught by the first nurse who went to pull insulin-this was also long before we had the solostar and other pens for insulin. The tech was training another tech how to load the Pyxis. The trainee said that he did notice but didn't say anything because he thought maybe he was mistaken, and didn't want to rock the boat because his trainer was his senior and very well respected. I wonder if this may have been the case for the orientee here as well.

Take away--ALWAYS, ALWAYS, ALWAYS go by the 5 rights, you will never go wrong! And never be afraid to question someone training you if you see something you are unsure of. You may just save a life!

[LilPeanut, MSN, RN, NP]

21 hours ago, Ray Southwell said:

<snip> Then I read the book, “Too Err is Human.” Published by the institute of Medicine. <snip>

Ok, please don't take huge offense, but I found the irony of that particular homonym error delicious.

17 hours ago, MunoRN said:

I'm not sure why we're so insistent on defining conditioned subconscious behaviors as instead being a conscious choice. Had she been consciously aware she was pulling vecuronium instead of midazolam I'd be right with you in your reasoning, but I'm not sure where you're getting that from.

Conscious decision to disregard procedure. That's what she did. She didn't consciously pick the vec, but just like a texter and driver doesn't think that what they are doing is going to cause problems (disregarding procedure)

16 hours ago, MunoRN said:

One of the problems with Pop-up-warning-whack-a-mole is that the person becomes conditioned to unconsciously seeing this as distractions when used excessively (which most ADCs do) so by definition they aren't reading them, and many of the more common pop-ups for sedating medications would be the same ones for vecuronium and midazolam.

The orange stickers are often on the top of the cubbie lid, which is of no use since the lid automatically pops open, but we often overuse these warning stickers deconditioning ourselves to their importance.

I just had to reconstitute an antibiotic the other day that I've never had to reconstitute before, I think we may be overestimating the consistency of medication preparations.

Actually, they showed a picture of the actual accudose drawer. It's a neon orange sticker on the cubbie itself, not just the lid. There was also a baggie/band with a warning that she removed.

15 hours ago, RegisterednurseRN02 said:

I think she majorly effed up! That is my opinion! But, it was not intentional! I think if we start hating on people in healthcare who do make mistakes that even some of us deem INAPPROPRIATE mistakes, people are going to be scared to become healthcare employees! It won't be worth it eventually! Yaya, check this check that, she made an effed up mistake. There is NO doubt..it was a horrible mistake! I personally think the simple solution is doing the 5 patient rights but that concept she clearly knew..I am 100% sure if she knew she was going to make this fatal error that day, she would of CALLED IN! There is a fine line between accepting that this person made a horrific mistake and deamonizing (sp) this person as well. It could have been ANY of us!!!!

Read this story: this nurse was an OB nurse for years maybe 20...and mixed up a medication while caring for a pregnant teen! This woman was given her license back but would not take it back! She worked overtime and slept in a hospital bed for 4 hours because they did not have staff for the next shift over the 4th of July. This is a horrible error, but being human, it could have been ANY of us..HER OWN EYES saw the wrong med on the medication bag...she DID HER CHECK and her own exhaustion failed her! It is heartbreaking and scares me to death to be an RN!!!

https://madison.com/news/state-nurse-error-caused-death-st-mary-s-hospital-could/article_a757c9c3-075e-5ff7-accf-2a6686e00ead.html

This case has been brought up because it was another prosecuted case. Honestly, in her case, I think she should have been prosecuted too. In her case, she deliberately chose to not use the scanner because she didn't like it. There were also ample warnings and it was her choice to work a lot of OT shifts in a row, sleeping at the hospital in a likely uncomfortable bed. What we do is dangerous and can kill people. A little bit of fear is healthy.

13 hours ago, MunoRN said:

It's actually both; less warnings and other mechanisms that are well known to be ineffective, and fix the lack of mechanisms that would have prevented this.

It seems there's a reluctance to acknowledge the lack of systemic measures that could have avoided this incident because RV could have avoided it all by herself, which is absolutely true, she had many opportunities to avoid this error. I'm not saying this is your stance, but what I find particularly concerning, which has been expressed by other poster(s) is that we actually shouldn't have systemic error prevention measures because then RV wouldn't have sufficiently learned her lesson to be more diligent. Personally, my goal is prevent all fatal errors using any means necessary.

No, what we're saying is that people are talking out of both sides of the case - too many error messages, not enough error messages. There aren't safeguards that you can put in place to prevent outright negligence/incompetence. It should be more about how do we identify incompetent and negligent nurses and get them out of the profession or at least away from a critical care situations.

[pearybrown]

On 2/28/2019 at 6:18 PM, Wuzzie said:

I can 100% say that a situation like this would never happen to me. That isn’t hubris or egoism or a lack of self-awareness as I have made a med-error in my past. But I have never and will never play it so fast and loose with multiple basic nursing standards that I put my patients at risk for harm or death. That admonishment just doesn’t wash with me and even if it were true that doesn’t excuse what RV did.

An error is an error and this case shines the big light onto many. Not declaring the error until she was forced to do later will cause her to go to jail unless she pleads out to a lesser charge. Like she never claimed a fault until caught.

[Ray Southwell]

Let me try to explain another way.

Please refer to the publication of "To Err is Human."

Here are some statements:

“Errors can be prevented by designing systems that make it hard for people to do the wrong thing and people to do the right thing.”

“Medication errors alone, occurring either in or out of the hospital , are estimated to account for over 7,000 deaths annually.”

“The common initial reaction when an error occurs is to find and blame someone.”

“People working in health care are among the most educated and dedicated workforce in any industry.”

I am going to make the assumption each of us care about the safety of our patients. It has been my experience punishing nurses for mistakes does not help patient safety. Should we tract down every nurse who was involved with the estimated 7000 deaths related to medication errors and prosecute them? I was involved in a hospital union leadership for years after reading the books from the institute of Medicine.

I was able to implement a policy of peer review. It was important to me that nurses determine who were the nurses not qualified to be working in a particular department. Administration determined one nurse should be fired for a mistake. I had her fellow nurses do a peer review. This nurse was well liked. But patient safety overruled friendship. She had been a new nurse who had been placed in a department that was over her novice nursing experience. Her nursing friends privately expressed their concern she needed more nursing experience prior to working a high intensity department. Rather than be fired she was given the opportunity to work in another nursing department in the hospital with far less intensity.

I have read much of the CMS report. Significant facts their. Still have questions. So let me start there.

What did the other nurses think about having this “help nurse” help them care for their patients. It has been my experience we are very protective of our patients. After all we are patient advocates. If we question the knowledge and skills of other nurses do we want them caring for our patients?

How many med errors has this nurse made during her employment at this hospital?

Was she full time employee or part time?

Now let me get to the facts presented in the CMS report.

She was what they called a “help nurse.” She did not have a patient assignment. The patient was a neuro patient on a neuro floor. The primary nurse caring for the patient was in orientation.

The patient was to have a PET Scan. She was brought to the imaging department. She told the tech she was claustrophobic. The primary nurse was notified and Versed was ordered. Imaging tech asked their department’s nurse(s) if they could administer the med. It was a busy day in the Imaging department. They needed to get this test done or send the patient back to the floor. The nurse(s) were/was too busy to give the medication because they would need to stay with the patient after giving Versed. So the imaging tech called the nursing floor and asked if some nurse could administer the med. The primary nurse asked the Help Nurse if she could give the medication. She could.

Thinking the medication had not been entered in the pyxis she overrode the alert and took what she thought was Versed. All the while the primary nurse was talking with her.

The Help Nurse did not know where Pet Scan was in the hospital she had to ask directions. The medication was given to the patient in a holding room and the nurse left. Some 30 minutes later a transporter arriving in the holding room noticed she was not breathing. A code was called and the patient intubated and sent to ICU.

The help nurse made a deadly error. But to err is human. Can we as professional look outside the blame game?

1. It is my understanding this nurse had minimal experience. Having worked for about 2 years as a nurse.
2. I see a help nurse much as I see a supervisor. They need to have vast experience so they can help with the care of patients they know little about. They need to know the hospital well along with policy and procedures.
3. Imaging department was behind schedule. Either the medication needed to be given or they would cancel the procedure. I wonder if the physician would be angry if the PET scan was canceled?
4. Nurses are frequently under pressure to get their job done faster.

How to improve the system:
1. Only nurses in the imaging department may give medications in their department.
2. vecuronium needs to have a second nurse sign before it is dispensed. Think how easy this safety procedure could have been with the second nurse standing by.
3. All nurses giving Versed have extra medication training on the need to monitor patients.

The bottom line; we as professional can and do find ways to improve patient safety when we step outside the blame game.

I am so pleased we have improved automobile safety because as a nation we looked at improving safety rather than blaming individuals for all car crashes. I think back to the lives lost because of car crashes resulting in deaths from broken glass. Development of safety glass. For to Err is Human.

[Wuzzie]

8 minutes ago, Ray Southwell said:

Can we as professional look outside the blame game?

We are not playing a blame game here. I have examined the same documents you have and have come to a different conclusion. A nurse with two years experience is not “minimally” experienced. That would be a new grad. She, herself, said she was comfortable giving Versed. Yet, after identifying that she knew it did not need to be reconstituted she still did not look at the dang vial to see why this time the formula was different. This is not an error. This is a willful choice to play it fast and loose. You’ve listed the circumstances. Care to have me list every single thing she did wrong? I’m mystified that anyone could look at the multiple, multiple poor choices she made and continue to think this was some sort of little lapse due to the fault of everyone and everything else. At what stage of your nursing education did you learn the 5 rights? How much experience is necessary to understand their meaning and importance?

[Ray Southwell]

Yeah. Lets throw her in prison. That will help improve patient safety.

Or will it chill future nurses of sharing their failures so others can learn.

Experience is the best teacher. Sharing experiences comes in a close second.

Perhaps you need to understand the nurses developmen to expert level.

https://www.medicalcenter.virginia.edu/therapy-services/3 - Benner - Novice to Expert-1.pdf

[Here.I.Stand, BSN, RN]

3 hours ago, Hoosier_RN said:

As far as checking the vial, even if she had selected the correct med in the Pyxis computer lineup, she still could have gotten the wrong med. Years ago, when the last hospital I worked at first got the Pyxis, a pharm tech accidentally loaded heparin into an insulin bin-this was before warnings were blaring on heparin vials. Luckily, it was caught by the first nurse who went to pull insulin-this was also long before we had the solostar and other pens for insulin. The tech was training another tech how to load the Pyxis. The trainee said that he did notice but didn't say anything because he thought maybe he was mistaken, and didn't want to rock the boat because his trainer was his senior and very well respected. I wonder if this may have been the case for the orientee here as well.

Take away--ALWAYS, ALWAYS, ALWAYS go by the 5 rights, you will never go wrong! And never be afraid to question someone training you if you see something you are unsure of. You may just save a life!

This! In my ICU, most of our liquid PO meds come in prefilled oral syringes. A few years ago I had a syringe of Tegretol with a “correct” label — correct meaning aligned with the order and properly barcoded. However, according to the concentration of the med, the syringe actually contained a double dose.

I got no error pop up when I scanned the med — because the LABEL was “correct.” But I gave the correct amount, because I learned a little med administration practice called “5 Rights.”

Technology is fallible. It’s a tool, but it’s not a substitute for a nurse using the brain that the public trusts us to use.

RV unfortunately ignored BOTH the tech safeguards AND the 5 Rights. And a woman is dead.